Advocate Illinois Masonic has a committee that we have fondly named the ED-BH (Emergency Department - Behavioral Health) Committee which meets for one and half hours monthly chaired by the Chair of Emergency Medicine. Members of the Committee include ED and Behavioral Health leadership as well as leadership and direct line staff representing the inpatient psychiatric unit, pharmacy, consult liaison service, behavioral health, emergency department, public safety and care management. This committee tracks data about our performance with behavioral health patients in the emergency room (length of stay, # and length of standbys, # and length of restraints, compliance with seclusion and restraint orders, etc.). This is also the venue where concerns, missteps, and process improvements are discussed, developed and implemented.

The Emergency Department is staffed 24/7 by a DMH-funded Crisis team comprised of licensed clinicians. The Crisis Team also sponsors 9 - 12 masters and doctoral level trainees each year. We have "non-traditional: practicum schedules so trainees are scheduled to work with their Crisis Supervisors, days, evenings and weekends (this helps to increase the depth of the Crisis Team, and is particularly helpful in those times when the number of behavioral health patients is high). The Emergency Department has a three room wing (the "EDP": Emergency Department-Psychiatric) for the most acutely ill psychiatric patients. Because the Department often has 6-12 behavioral health patients, less acute patients are put in a designated section of the main ED. The Crisis Worker and the Nurse frequently "huddle" (consult with one another) to ensure that the placement of patients in optimal (e.g., who needs a private room, in which area). When the police bring in a behavioral health patient an overhead code is made on the PA system. A representative from medicine, nursing, the crisis team and public safety greet the police officers and the patient who is asked to sit in a comfortable chair in the EDP. A brief assessment is done at that time which includes an assessment as to whether medication is needed. The emphasis is on starting treatment within 1 hour of arrival.

The Emergency Department is stocked with two DVD players, a range of movies, English and Spanish language magazines, playing cards, journaling materials, lists of AA meetings, psycho educational materials and an i-pod which plays calming music on docking system. The Crisis Worker reviews the Safety Plan with each patient and this plan is kept with the chart so that each of the providers (nursing, medicine and crisis) are aware of the patient's stated preferences for how to remain calm and safe during the ED stay.

Each morning a psychiatrist rounds on behavioral health patients with longer lengths of stay in the Emergency Department. The psychiatrist consults with the Emergency Department attendings around issues of medication, continuing stabilization and care planning. The Crisis Clinicians provide frequent bedside interventions for the behavioral health patients. For those patients with longer lengths of stay, the combination of intensive therapeutic and medication stabilization and contact with collaterals sometimes provides sufficient improvement so that the patient can be discharged from the Emergency Department with a plan for follow up care which always includes an appointment with Behavioral Health Services or another community-based mental health organization within one week and medication script (for up to four weeks of medication depending on the patient's unique situation). The first month of medication for indigent patients is paid for out of the medication fund provided by DMH. A psychiatric appointment is given within two weeks of the intake appointment and indigent patients can access entitlements advocacy at their intake appointment so that a longer term plan for accessing ongoing medication can be made.

USING THE "SAFETY PLAN"

Introduce the Safety Plan upon medical clearance when it has been determined that our patient will need a transfer to inpatient psychiatry for safety and protection.

Educate the patient on the possible LOS when being transferred and our concerns for them taking and active role in self care by participating in behavioral health care advance directives.

Answer any questions the patient may have about the Safety Plan. In addition explain the benefits of soothing activities when anxious. Our goal is to help them during this moment of Crisis.

Respond quickly to requests for supportive items to encourage success.

Before the patient leaves, the Crisis Worker may encourage the patient to educate others about which therapeutic strategies or activities are most helpful.